Esophageal Cancer
Incidence Esophageal cancer is not common; however, rates are increasing. Annually in the US, there are approximately 16,500 new cases of esophageal cancer diagnosed and 14,300 deaths from esophageal cancer. The 5-year survival rate remains low at 34%. The incidence of esophageal cancer increases with age. Individuals between ages 70-84 have the greatest risk. There is a higher incidence in African Americans and Alaska Natives than in whites. Men have esophageal cancer rates that are three times greater than women. Risk Factors The cause of esophogeal cancer is unknown but risk factors include Barrett's metaplasia, smoking, excessive alcohol intake, central obesiry, and diet intake that is low in fruits and vegetables. Patients with injury to the esophageal mucosa are also at greater risk. Occupational exposures to asbestos and cement dust have also been linked to the gender differences in esophageal cancer rates. An esophageal tumor, located in the middle and lower portions of the esophagus, can be malignant and often advances before any s/s occur. Signs and Symptoms The majority of patients have advanced disease at diagnosis but progressive dysphagia is the most common symptom and my be described as a substernal feeling as if food is not passing. Initially the dysphagia occurs only with meat, then soft food and eventually liquids. Pain develops late and is described as occurring in the substernal, epigastric or back areas. If tumor is in the upper third of the esophagus, symptoms such as sore throat, choking and hoarseness may occur. Weight loss is fairly common. How is it diagnosed? Endoscopic biopsy is necessary to make a definitive diagnosis of carcinoma by identification of malignant cells. Endoscopic ultrasonography (EUS) is used to stage esophageal cancer. Barium swallow with fluoroscopy may show narrowing of the esophagus at the tumor site. Bronchoscopic examination may ber performed to detect malignant involvement of the lung. CT scanning and MRI are also used to assess the extent of the disease. Medical Treatments The treatment of esophageal concer depends on the location of the tumor and whether invasion or metastasis has occurred. The best results may be obtained with surgery, endoscopic ablation, chemotherapy, and irradiation. The types of surgical procedures done are: * Esophagectomy: removal of part or all of the esophagus with use of a Dacron graft to replace the resected part. * Esophagogastrostomy: resection of a portion of the esophagus and anastomosis of the remaining portion of the stomach. * Esophagoenterostomy: resection of a portion of the esophagus and anastomosis of a segment of colon to the remaining portion. * Surgical approaches may be open or laparoscopic. * Minimally invasive esophagectomy (e.g., laparoscopic vagal nerve-sparing surgery) is being used with increased frequency. Endoscopy approaches using photodynamic and/or laser therapy are performed to ablate high-grade metaplasia of Barrett's esophagus. Treatment for esophageal cancer also includes neoadjuvant chemotherapy with or without radiation therapy, Concurrent radiation and chemotherapy are administered for palliation of symptoms, especially dysphagia, as well as to increase survival. * Palliative therapy consists of restoration of the swallowing function and maintenance of nutrition and hydration. Dilation, stent placement, or both, can relieve obstruciton. After esophageal surgery, parenteral fluids are given. A jejunostomy for gastrostomy feeding tube may be placed after surgery. Nursing Management (Nursing Process) Nursing Assessment: * Ask patient about history of GERD, hiatal hernia, achalasia, or Barrett's esophagus. * Ask about tobacco or alcohol use. * Assess the patient for progressive dysphagia and odymophagia. * Ask the patient about which foods cause dysphagia (meats, soft foods, liquids). * Assess for pain, choking, heartburn, hoarseness, cough, anorexia, weight loss, and regurgitation. Nursing Diagnoses: * Risk for aspiration * Deficient fluid volume * Chronic pain * Imbalanced nutrition: less than body requirements * Ineffective health maintenance * Anxiety * Grieving Planning: The overall health goals are: * The patient will have relief of symptoms, including pain and dysphagia. * The patient will achieve optimal nutritional intake. * The patient will understand tee prognosis of the disease. * The patient will experience a quality of life appropriate to disease progression. Nursing Implementation/Interventions: * Counsel patients with GERD, Barrett's esophagus, or hiatal hernia regarding regular follow-up evaluations. * Health counseling should focus on eliminating smoking and/or excessive alcohol use as well as other risk factors for GERD. * Encourage maintenance of good oral hygeine and good dietary habits. Perform meticulous oral care while patient is in the hospital. Teaching about tube feeding and TPN may be necessary. * Encourage patients to seek medical attention for any esophageal problems, especially dysphagia. * Provide teaching about chest tubes, IV lines, NG tubes, pain management, G- or J-tube feeding, turning, coughing, and deep breathing. * Provide postoperative care. Assessment of tube drainage, maintenance of the tube, and oral and nasal care are nursing responsbilitiess. Evaluation: The expected outcomes are that the patient with esophageal cancer will: * Maintain a patent airway * Have relief of pain * Be able to swallow comfortably * Consume adequate nutritional intake * Understand the prognosis of the disease * Experience quality of life appropriate to disease progression